A Country Doctor Writes:

The Family Doctor used to be almost the only source of medical information patients had access to. Now, few people need us to bring them the latest news. It’s there for everyone to see. There’s even too much of it.

Today, our role is to help make sense of it all. In order to do that, we must possess and project authority, but we have no reason to put ourselves on any kind of pedestal.

In our culture, evidenced by the stories we read, the movies we watch and many of the ways we interact with the world, people see themselves as heroes of their own lives, the main actors in their own narratives. Most Westerners aspire to reach higher levels of skill, status, health or wealth. We, deep down, generally don’t connect well with heroes who are flawless and obviously much better than we are, and we identify the deepest with products, companies and professionals who help us move toward our personal goals.

Today’s business literature urges entrepreneurs and business leaders to take on a supportive role rather than flaunt their achievements or expertise. “Be the Guide, Not the Hero” is a quote from Donald Miller of StoryBrand.

The dominating narratives present a flawed, insecure hero, who faces challenges while also reaching a higher level of insight, and he or she is supported by a guide who is older or wiser (Obi-Wan Kenobi or Yoda) but in no way competing with the fledging hero. These characters have been there, done that, and have nothing to prove. They are portrayed in ways that indicate they are supremely competent and yet almost self effacing. It is not their turn to shine.

That is a useful way for doctors to think of themselves. We must support our patients in their own pursuit of health and happiness. They must find out or choose for themselves. We can not make them do things that they don’t see or feel by themselves. And we have no right to expect that they will always follow our advice.

Our quality metrics can make us feel as if we are the main characters, or heroes in the story analogy, in our interactions with our patients. The results of our efforts can make us feel as if we are experiencing success or failure. This in turn can create job stress and burnout.

By adopting and staying in the role of Guide, physicians can preserve their stamina and enthusiasm for each and every patient encounter. We offer guidance, but every hero is free to choose whether or not to accept our words of wisdom.

Today’s news if full of commentary about work requirements for Medicaid. Is work a prerequisite for healthcare or is health a prerequisite for work?

Not to complicate things, but can we even agree on what healthcare is? I don’t think we can, and it largely falls back on what we want to share in paying for.

A patient with an ugly skin lesion can have it removed if it might be cancer or if it bleeds or causes pain. If it is just ugly, it’s considered cosmetic, and insurance won’t pay for it.

A man wants a vasectomy, while another one regrets having one and wants it reversed. Is one procedure more medically necessary than the other and more deserving of societal cost sharing?

Even the most esoteric medical procedures, like freezing embryos or cloning children, could be called healthcare, but may not have society’s support when it comes to being necessary or desirable.

And, even as we speak, what about abortions? Are they healthcare or not?

In many ways, I think life was simpler practicing medicine in Socialized Sweden. The Government paid and the Government made the rules. Here, the Government makes some rules, the insurance industry makes others; the Government pays for some people’s care and the insurance industry pays for others. And the insurance companies all have different rules.

Since healthcare costs twice as much in this country as anywhere else in the world, it seems painfully obvious that we need to talk about what the purpose of healthcare is and, from a moral perspective, what we have a right to expect our fellow countrymen/women (if not citizens) to pay for.

It is remarkable that such an enormous slice of our budget and our life so much lacks definition and almost seems to be taboo to openly try to debate.

If we look at other aspects of cost sharing in our society, can we draw any useful parallels?

If a high school senior wants to repeat his senior year because he had so much fun, should he be able to do it for free? (Just a hypothetical example, I don’t know if anyone would really want to.)

If a child calls the fire department every time she smells smoke from the family barbecue, should the town charge the family or stop sending a fire truck?

If an amateur sailor capsizes every weekend and always calls Marine Patrol, should they keep responding?

In social policy terms, the word entitlement is used to define programs like Medicare and Medicaid. I think that is an unfortunate and very loaded word. Contrast that with another word that I personally keep coming back to: Stewardship.

It is time for a serious conversation about balancing stewardship and entitlement in healthcare. At least as long as it is not all self-pay: Taxes or insurance premiums both imply we want someone else to pay for some or much of what we think of as our personal healthcare.

For many years, I’ve held a brief huddle with my team every morning to make sure we are ready for the day: Anybody with complex problems coming in today? Anybody who’s been in the ER? How is Mrs. Jones’ husband over at the nursing home, is she worried about his condition? Where can we squeeze in more add-on’s?

Now other people have tried to hijack the word “huddle” for a completely different purpose. They want to use it to slow us down instead of helping get us get through the avalanche of issues we’re already expecting. In my other office they call it pre-visit planning. It’s not about having the MRI result available or the recent ER note, but more about who is behind on some aspect of their health maintenance and (unsuspectingly) expecting just a sore throat visit, but consistently avoiding their diabetes followup visits?

My veterinarian colleagues handle this differently. They just send a post card at random times, or hand me a paper, usually part of my exit statement, as I recall, that says which critter is due for what. But in that case I’m already safely close to the door and nobody is expecting me to act on it in that instant.

In human medicine, our quality ratings, and soon our paycheck, will depend on how effectively we convince patients to get caught up on their proscribed health maintenance.

In the retail world, they call that upselling. When I stop at a 24 hour gas station and buy some coffee for my long trip between my two offices, they always ask if I want some donuts or chips with that, maybe a banana or whatever. Same thing at the hardware store, if I buy a flashlight, they ask if I need spare batteries, and so on.

How fair is that to our patients?

I remember seeing a video about the hijacked kind of huddle, where the doctor and medical assistant almost gleefully talk about how to convince a noncompliant female patient to have her overdue Pap smear when she is only expecting something much less involved.

And all the while we are supposed to be patient centered and respect each patient’s own agenda. Too bad not everyone else has to…

Brilinta, at $6.50 per pill, twice a day, reduces cardiovascular events more than generic Plavix, which costs 50 cents per pill, once a day. But only a little – 20% relative or 2% absolute risk reduction. The event risk was 10% with the more expensive drug and 12% with the one that costs 82% less.

Put differently, if 100 patients were treated with Brilinta for a year, at a cost of $4,680 for each patient, 10 patients would still have an event. With clopidogrel, 100 patients, each one at a cost of $180, 12 events would occur. That means two fewer events would happen per 100 patients on Brilinta at an extra cost of $450,000, or $225,000 per avoided cardiovascular emergency (Number Needed to Treat, NNT=50).

This is described in a New York Times article as a profound ethical dilemma in medicine today:

“Some of us believed that a doctor’s job is to deliver the best possible care, period. Others argued that doctors should aim to find some balance between medical benefit, financial cost and social responsibility. It’s the kind of question that we aren’t really trained to solve. Are costs something that an individual doctor should do something about? What is a doctor supposed to do?”

As a Swedish born and trained physician, even though I now work in the United States, I guess I would claim that I was trained to solve this kind of question. Therein lies the fundamental dilemma of American medicine.

The American ethic of wanting to do absolutely everything possible for each patient has its roots in a different era from the one we live in now. It is a relic of a time when diagnostic tests, surgical interventions or medicines for everyday diseases didn’t cost multiples of average people’s annual incomes. It also came about in he era before the Government (Medicare and Medicaid) or risk pools of ordinary people (insurance companies, in stewardship of employers’ and wage earners’ premiums) became the payers of health care expenses. Back then, patients paid for their own health care, or it was offered as more or less charity care.

Americans don’t like to use the term Socialized Medicine, but that is what it works like when someone else pays for our care. We may use different words, like Socially Responsible Medicine. But “social” is part of it.

If I had just survived a heart attack and had a choice between clopidogrel and Brilinta, would my choice be different if I had to pay an extra $4,500 per year myself than if I could have someone else pay for it?

Would the latter choice possibly deprive other people of medicines, surgeries or vaccines they needed because of the vast number of people making the same choice at their fellow citizens’ expense?

Would my choice indirectly be someone else’s death sentence? All for a jump from an 88% chance of me being okay to a 90% chance? I could get the more expensive drug and make bad dietary choices, or forget a dose here and there and the nuance in efficacy between the two drugs might be moot – but certainly not the cost differential.

The operative word here, in English, is stewardship. I can’t even remember what it is in Swedish: Spending resources wisely, especially when those resources belong to all of us.

I can prescribe Suboxone for 100 patients in opioid addiction treatment. You start with 30 and can upgrade after two years. Some Suboxone prescribing doctors have a waiting list; only when a patient “graduates” or gets dismissed from the practice can a new one enter.

In the State of Maine, there are now limits on the doses of opioids we can prescribe, and as a result of the efforts to reduce, some patients have come off pain killers completely. But providers regularly get emails from the Prescription Monitoring Program telling us whether we have more opioid patients or prescribe higher doses than our colleagues.

The handwriting is on the wall: Doctors are continually and systematically shamed into reducing their opioid prescribing. It is an unpleasant situation.

Maybe, since Big Brother is obviously involved here anyway, we should just be issued quotas: Don’t make us guess how many patients on opioids are “too many”, just spell it out. The DEA already does it for Suboxone. That would be cleaner. And it would make it easier for patients to understand:

“Sorry, Jim, I had to cut 35 patients from my opioid roster this year and you turned out to be one of them. Nothing personal…”